anexa 5

CMI Dr. _______________

CF: ___________________

Nr. _____/___.___._______

SCRISOARE MEDICALĂ

Către Comisia de Expertiză a Persoanelor cu Handicap

Numele şi prenumele: ______________________________

CNP: _______________________, Vârsta: _______ ani

1. Anamneza ______________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

a. antecedente personale patologice

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

2. Diagnosticul medical a. principal

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

b. altele

______________________________________________________________

______________________________________________________________

______________________________________________________________

3. Certificatele medicale actuale (se specifică numărul, data, instituţia

emitentă şi numele medicului care a eliberat certificatul)

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

4. Internări în spital (data, instituţia emitentă şi diagnosticul la ieşirea din

spital)

______________________________________________________________

______________________________________________________________

______________________________________________________________

5. Persoana Persoana se poate / nu se poate deplasa.

Data completării

_____________________________

Semnătura şi parafa medicului de familie

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